LOUISVILLE, Ky. -- Angela Bale had been feeling breathless and exhausted for weeks when she doubled over while riding in a friend's car — the victim of a heart attack.

She was a thin, active 35-year-old and had gone repeatedly to a doctor, who told her she had a sinus infection.

"I couldn't believe it. A heart attack? That doesn't happen to somebody like me," said Bale, who is now 46 and the victim of two more heart attacks.

Experts say many women — and many of their doctors — have the same mistaken impression. On Saturday the University of Louisville, in conjunction with KentuckyOne Health and U of L Physicians, sought to change that by holding the Louisville Symposium on Heart Disease in Women at the Jewish Hospital Rudd Heart and Lung Center.

The goal is to educate health professionals, women and their families about how to prevent, recognize and treat the potentially deadly condition.

"Heart disease is the biggest killer of women. People think it's breast cancer, but that's not even close," killing about one-tenth as many, said Dr. Kendra Grubb, a cardiac surgeon who conceived the event. "When I came from New York City, I realized there was a huge lack of knowledge among front-line health care providers and the public."

The American Heart Association, which also focuses on the issue through its Go Red for Women campaign, says cardiovascular disease kills 400,000 American women each year. In Kentucky, heart disease and stroke claim 16 women a day and nearly 6,000 a year, representing 29 percent of all female deaths.

Risk factors such as smoking, obesity, high blood pressure and diabetes are rampant among women across the state.

Complicating matters, women with heart disease often have different symptoms than men, such as back or jaw pain instead of the crushing chest pain men describe.

Women are also more likely to deny the problem, doctors say, partly because they tend to put their own health on the back burner while caring for others.

"There's a huge amount of denial. They say, 'This couldn't possibly be my heart,' " Grubb said. "Really, it's just very important to increase the level of awareness."

Two women's hearts

Bale, a bank auditor and mother of two from Horse Cave, Ky., traces her heart disease to genetics. While her parents never had it, her mother's father and his eight siblings all died of heart disease. She also smoked a pack of cigarettes a day for nine years before her first heart attack in 2002, quitting that day and never lighting up again.

After her first heart attack, Bale had two clot-buster shots and angioplasty to widen a coronary artery known as the "widow maker" before having a stent implanted. But the same artery became blocked twice more, leading to heart attacks in 2008 and 2013. Over a dozen years, she's had about nine angioplasty procedures and five stents — and bypass surgery in April.

“'Heart disease is the biggest killer of women. People think it's breast cancer, but that's not even close.'”

Dr. Kendra Grubb, cardiac surgeon

Nurse Theresa Byrd, clinical coordinator of the women's heart and vascular center at Norton Suburban Hospital, said women are more prone than men to recurrent heart attacks and have higher rates of congestive heart failure.

"Overall," she said, "women have a poorer prognosis."

Theresa Christopher, 60, of Louisville, said she never thought her high blood pressure and high cholesterol would one day lead to triple-bypass heart surgery. She never smoked, avoided fried food, did water aerobics, and generally took good care of herself.

But when she began feeling a burning sensation in her chest while rushing around, she told her doctor at her regular checkup last November. She said he ordered an electrocardiogram but didn't seem overly concerned.

She wrote it off to stress, since she recently lost her husband, put her father in a nursing home and was working full-time as assistant to the dean at Louisville's Kent School of Social Work.

Grubb said her reaction was not unusual. "We are not catching it as early as we could because women put it off as stress," she said, meaning the disease is often further along when women are finally diagnosed.

In April, Christopher recalled sitting at her desk and feeling a dull pain in her chest move up to her neck. She immediately sought help, having read that heart disease symptoms were subtler in women than men. In fact, studies show that nearly two-thirds of women who died suddenly of heart disease had no previous symptoms.

Doctors told Christopher she had blockages in three arteries. She underwent cardiac catheterization May 9 and open-heart surgery with Grubb on May 13.

"My advice to other women is to pay attention to your symptoms," she said. "If it happened to me, it could happen to anyone."

More work ahead

Awareness of heart disease among women is gradually rising, Grubb said, but far more needs to be done. She called the heart association's Go Red campaign "a good start" but said it seems to do a better job reaching businesswomen than economically marginalized women with less access to health care.

Byrd, who helps with the Go Red campaign, disagreed, saying Norton works closely with the campaign to provide speakers and screenings at African-American churches and plans a health fair at the Americana Community Center, which serves immigrants and refugees.

Byrd said Norton is also reaching out to new mothers who have suffered from gestational diabetes or pregnancy-induced high blood pressure and are at higher risk for heart disease.

Grubb and Byrd agreed that while raising awareness is a challenge, even more difficult is changing the poor health habits that can lead to heart disease.

Kentuckians have the nation's highest smoking rate, are less active than Americans overall, and are less likely to eat the recommended amounts of fruits and vegetables. More than six in 10 Kentucky women are obese or overweight and nearly a quarter smoke cigarettes.

"We have a lot of work to do," Byrd said, "especially with obesity and smoking."

Grubb said it will also take awhile to educate health professionals about women's hearts. A 2010 study in a heart association journal said only 34 percent of clinical trial subjects in cardiovascular research are women.

"Now, the textbooks are written for men. All of the data comes from what we've learned from men," Grubb said, adding that this is only beginning to change.

Grubb said the stakes are high, since heart disease takes a heavy toll on women.

In Bale's case, heart attacks have reduced her stamina, making it difficult to indulge her passion for gardening or keep up with her teenage daughters. She spends three days a week in cardiac rehabilitation.

"It's changed my life. It's made me worry about what's going to happen to my children if I have another heart attack," she said. "It becomes your 'normal.' You're always aware it can happen again."